For carefully selected stroke patients, endovascular thrombectomy is beneficial at 6 to 16 hours after onset (DEFUSE)

Reference

Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018;378:708-718.

Synopsis

Previous randomized trials have demonstrated a benefit to early endovascular thrombectomy, within 6 hours of the onset of symptoms. These researchers identified patients with stroke in whom the clinical deficit was disproportionately large compared with what was seen on imaging, presumably indicating that ischemia rather than infarction was the cause of some of the deficit. The researchers created criteria to identify patients between 6 and 16 hours from the onset of symptoms who had a large area of ischemia based on computed tomography scan and magnetic resonance perfusion imaging. The 182 participants were randomized to endovascular thrombectomy plus standard medical therapy for stroke or standard medical therapy alone. Their median age was 70 to 71 years, half were women, symptoms were present on waking up in approximately half of patients, and the median time from symptom onset to reperfusion was approximately 12 hours. The primary outcome was the modified Rankin score at 3 months, as assessed by researchers masked to treatment assigned. At that time, the endovascular therapy group had a statistically significant 1 point median improvement in the Rankin score, which is similar to going from moderately severe to moderate disability. Patients in the endovascular therapy group were more likely to have no worse than a slight disability (Rankin score 0 – 2; 44% vs 16%; P = .001). Regarding potential harms, there were fewer deaths in the endovascular therapy group, though this difference was not statistically significant (14% vs 26%; P = .05), and no differences in symptomatic intracranial hemorrhage (7% vs 4%; P = .75), early neurologic deterioration (9% vs 12%; P = .44), or parenchymal hemorrhage (9% vs 3%; P = .21) between groups.